Congressional briefing highlights Department of Defense’s long war against a surprising enemy: malaria

On Monday, the United Nations (UN) members unanimously adopted a high-level political declaration on universal health coverage (UHC), which World Health Organization (WHO) Director-General Dr. Tedros Adhanom Ghebreyesus called a “landmark for global health and development.” While the adoption of the declaration is welcome news, in many ways it represents a starting point for the next phase of UHC, in which the thornier issues of financing, follow through, and accountability will rise to the forefront. UHC declaration adopted unanimously at United Nations High-Level Meeting It was a bit of a bumpy journey to Monday’s political declaration. After months of tense negotiations among member states, the UHC debate had stalled over two hot-button issues—sexual and reproductive health and the rights of migrants and refugees—which weren’t resolved until a few days before the High-Level Meeting. Thankfully, countries were able to push the UHC declaration across the finish line, with a several countries, including the United States, disassociating themselves from the provisions linked to those thornier issues. It was encouraging to see that the final declaration was inclusive of GHTC-supported language on research and development (R&D), focused in particular on innovative financing for new products and technologies, emphasizing the role of the private sector and new models for sustainable investment.  “This declaration represents a landmark for global health and development,” Dr Tedros Adhanom Ghebreyesus The UHC process now moves into a new phase: countries are tasked with developing their own strategies or national action plans to fulfill these commitments and advance UHC within their own borders. The agreement is intended to be country-led, and as member states adopt the commitments to their own geographic contexts, they must outline a clear path for how they will mobilize their governments and increase investment in UHC.  Assessing gaps in the tools to mitigate each countries’ priority health challenges also needs to be considered as part of this new phase.  It’s all about the money Now that countries have committed to UHC, how will they pay for it? That question seemed to be on everyone’s mind as numerous events throughout the week of the UN General Assembly focused on the financing side of UHC. The message was clear: not enough is being done, particularly on domestic resource mobilization. Most countries don’t have a UHC investment strategy to achieve the lofty goals set forth in the UHC declaration and the Sustainable Development Goals. As countries start to develop their health investment plans, it is crucial that investment in R&D remain an integral pillar. UHC cannot be achieved without stepping up the fight against the world’s endemic and emerging infectious diseases. This will require new tools and technologies, as was echoed by stakeholders throughout the week, including Global Fund Executive Director Peter Sands and Dr. Tedros. We also need to invest more in the uptake and scaling of innovations and technologies and ensure that we are thinking of end-to-end solutions.  "Existing tools won't be enough"@PeterASands highlights that innovation hasn't been fast enough. We need to push more aggressively to scale up innovation and integration of new tools. @GlobalFund #TBinnovation #HealthForAll pic.twitter.com/7tSluSlIL5— GHTC (@GHTCoalition) September 22, 2019 There were several side events this week on financing reforms, tax redistribution into UHC—from the tobacco industry, for example—and the need for innovative financing approaches. Outcomes-based finance such as social impact bonds and blended finance models, in particular, attracted some attention. All countries did commit to spending one percent or more of their GDP on public health as part of the declaration. That is likely insufficient to achieve UHC, but money isn’t the only factor for success. Some countries, such as the United States, already spend more on health care but still lack access to coverage for all citizens.  Accountability emerges as central focus after the political declaration Now the real work begins. Many speakers this week devoted time to discussing the challenge of accountability and follow through, drawing on past experiences from other high-level meetings.  Stakeholders recognized that the declaration is just a starting framework and that the lofty language needs to be translated into tangible actions and investment. While this declaration symbolizes a major shift for the global health agenda, fears persist that the momentum will dissipate and that countries won’t be able to follow through on their commitments by 2030—just over a decade from now.  Those fears are warranted. Just last week, WHO published a report stating that while advances have been made on UHC, as many as five billion people will be left without full access to healthcare in 2030 at the current rate of progress. Countries must set clear targets for moving their populations on the journey towards UHC and create specific metrics through which progress can be monitored. Mechanisms and incentive structures must be put in place to allow for follow-up and accountability, underscoring the political will expressed in New York this week. In adopting the declaration, member states have committed to investing in policies which would allow everyone, everywhere to have access to quality health care products and services without financial hardship. Leaders must now pivot to move from commitment to concrete action.

A crisp chill hung in the air one early morning last week as members of the GHTC team stepped up the stairs adjoining the newly refurbished Apple Carnegie Library in Washington, DC, to pose for a photo with more than one hundred fellow research and development (R&D) advocates from across the country. GHTC was joining these representatives from more than 350 organizations as part of the Rally for Medical Research. Later that day, we would all descend upon Capitol Hill to implore lawmakers to increase funding for the National Institutes of Health (NIH). For GHTC, increasing the NIH budget is a clear priority to improve global health—but our team was also at the Rally on another mission: to show that global health and domestic health R&D advocates can and should work together to achieve our shared goals.The Rally for Medical Research was launched in 2013 with a speech given from atop those same stairs. That year, NIH funding was at risk of sweeping budget cuts. But in every year since the launch of the Rally, with health R&D advocates, patients, and scientists coming to Washington to advocate collectively for investments in NIH, the agency’s budget has grown. In fact, over the last six years, the NIH budget has increased by more than one-third—showing dramatic growth after a decade of stagnation. This year, advocates requested an increase of at least another US$2.5 billion, which would bring total NIH funding to $41.6 billion.On the steps of the Carnegie Library, GHTC stood side by side with advocates who were patients, caregivers, and researchers. Almost every advocate there was focused on a health priority affecting Americans, and so that morning, we were unsure how our globally focused message would land. But we planned to stick with our conviction: that domestic health R&D and global health R&D should and do share many of the same priorities.And for the rest of the day, we marched around Capitol Hill and made that argument to anyone who would listen.The first and most intuitive point we would make is that NIH-funded research for American health also benefits global health. You can often trace the streams of new domestic and global health technologies to the same wellspring of basic research. For example, in the 1980s when little was known about HIV and AIDS, the NIH was at the forefront of uncovering its basic biology. Later NIH research helped kickstart many of the technologies now used around the world for HIV and AIDS treatment and prevention. With advancements in R&D tools and strategies—such as artificial intelligence and the repurposing of drugs already approved by the US Food and Drug Administration (FDA)—it will only become easier to find global health applications from domestically-focused R&D.But the flow of R&D from the United States to the rest of the world is only part of the story. At the Rally, we tried to share a more nuanced narrative, explaining that the reverse is also true: when the United States invests directly in R&D for global health aims, that research often returns to benefit Americans. For instance, pre-exposure prophylaxis, or PrEP, is now commonly prescribed to prevent HIV infections for at-risk Americans and is a key part of the newly announced strategy to end HIV in the United States over the next decade. Many lawmakers may not realize, however, that PrEP was developed through clinical trials conducted mostly in low- and middle-income countries.Likewise, clinical trials for tuberculosis (TB) are often done abroad because they are difficult to conduct in the United States, where the patient population is small and dispersed. Pretomanid, a new antibiotic, is being called a game-changer for the treatment of highly drug-resistant TB. Its recent FDA approval as part of a combination treatment regimen was based on results from a clinical trial in South Africa and Tanzania. Now, in addition to treating patients around the world, the drug will be used in the United States to treat patients suffering from this deadly and most difficult to treat form of TB.And this unsung story extends to non-communicable diseases (NCDs). Research on NCDs abroad has led to insights on the NCD burdens we face at home. For example, hypertension research with African populations has helped illuminate how hypertension in African American populations is largely driven by social and not genetic risk factors. Another example is in the treatment of lupus, a painful autoimmune disease that affects up to 1.5 million Americans. It happens that some of the most effective treatments for lupus are anti-malarial drugs.The histories of both domestic and global health R&D are filled with examples of discoveries and technologies that start down one road and turn down another. It’s increasingly clear, however, that the R&D landscape is changing, and these roads will need to merge into a multilane highway of science and discovery. In the domestic health lane, the increasing number, novelty, and ambit of infectious and vector-borne disease outbreaks are driving investment in global health security and vector-borne disease research; in the global health lane, the increasing burden of NCDs in low- and middle-income countries is adding to the call for universal health coverage.Throughout the Rally for Medical Research, in four meetings with congressional staff and two meetings directly with members of Congress, we repeated these points alongside patients, family members, and friends who had direct experiences with pediatric cancers, rare diseases, and other devastating conditions. No facts or figures are as compelling as hearing the voice of someone who has direct experience with a condition, and so we were worried whether our talking points about R&D for diseases many Americans have never seen firsthand would sway congressional staff, members of Congress, and our fellow advocates—but every person listened. By the end of the day, we could tell the other advocates thought our stories strengthened, rather than detracted from, our shared advocacy message about the need for more investment in NIH. When our group finished the last meeting on our original schedule, a few other advocates approached GHTC and asked if we would be willing to participate in one more after-hours meeting with another member of Congress—and of course, we stepped up to join them.Too often in global health we cubbyhole ourselves and miss opportunities to work with our domestically focused advocacy counterparts who share our same fundamental goal: to improve human health and well-being. Many of these opportunities offer mutual benefit—and combined, our arguments are stronger. In the future, the GHTC US advocacy and policy team will continue to look for moments when we can stand with our fellow domestic R&D advocates as we did on that brisk morning. Like in R&D, the best progress often comes from working together.